Policy debates surrounding implementation of Accountable Care Organizations (ACOs) in the Medicare program would be informed greatly by a better understanding of the relationship between physician organization and the quality and cost of care. In this context, the candidate (Dr. David C. Miller) seeks to evaluate the organization of surgical practice in the United States and its relationship to efficiency. The candidate, a urologist and health services researcher at the University of Michigan, will leverage this proposal to broaden the scientific and clinical scope of his research agenda, and to facilitate his development into an independent investigator. During the period of support, he will pursue additional didactic instruction in several disciplines, including doctoral-level courses in advanced statistical and econometric methods (e.g., hierarchical modeling), health care organizations, and health care policy. He will also have ample opportunities for mentored, project-based learning, including the hands-on application of advanced statistical modeling and econometric techniques. The research plan has three aims: Aim 1. To understand the organization of surgical practice in the United States. Using both administrative and survey data, the candidate will determine the proportion of surgical care provided in four distinct organizational settings: 1) integrated delivery systems, 2) multispecialty groups, 3) single- specialty groups, and 4) solo or 2-person practices. He will also explore the relationship between physician organization and potential determinants of efficiency, including financial incentives and use of care coordination strategies. Aim 2. To examine the relationship between physician organization and quality of surgical care. Using national Medicare claims data (2006-2008), the candidate will then compare risk-adjusted operative mortality, rates of readmission, and post-operative complications among patients undergoing common inpatient procedures performed by surgeons working in the same four organizational settings. He posits that surgeons working in integrated delivery systems will have better outcomes, due in part to their greater capacity for information exchange and care coordination. Aim 3. To evaluate the relationship between physician organization and costs of surgical care. Finally, for the same physician organizations, the candidate will compare Medicare expenditures related to the index episode of surgical care. Specific costs to be assessed include (among others) overall hospital payments, payments for physician services, and payments for post-acute care. He hypothesizes that surgeons in single-specialty practices will provide more expensive care based on, among other factors, greater use of consultants, diagnostic tests, and post-discharge ancillary care. Completion of the proposed research will illuminate the potential quality and cost implications of Medicare ACOs and clarify the merits of a voluntary ACO implementation strategy.